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G�t�! �►�y G' i�e./f ft 1 �wc/ 7-07c wC`i irao�,rsvm•r-. <br /> Cj <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />:. FON;0 FICE USE: 1 1601 E. Hazelton Ave ' , Stockton, Calif. <br /> 11Y// i Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No. 7�_7/ <br /> THIS. PERMIT EXPIRES 1 YEAR- FROM DATE ISSUED Date Issued E, <br /> (Complete In Triplicate) f <br /> Application is hereby made to the San 'Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San -Joaquin Local Health District. <br /> .TOB ADDRESS/LOCATION L� k IN <br /> CENSUS TRACT <br /> Owner's Name S ens Phone - <br /> Address "A mr, City ' <br /> I i <br /> Contractor's Name ® era. License #/�Phone _•,� <br /> 40 <br /> TYPE OF WORK (Check).: NEW WELL /? DEEPEN /_7 RECONDITION f7 DESTRtCTION f7 ; <br /> PUMP INSTALLATION "./ / PUMP REPAIR -/ PUMP REPLACEMENT /7 <br /> Other — <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL_ PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial k Cable Tool Dia. of Well Excavation 6�1 <br /> Domestic/private i -Drilled Dia, of Well Casing <br /> Domestic/public i Driven Gauge of Casing ' <br /> _ ;?k . Irrigation 4 Gravel Pack Depth of Grout Seal <br /> Cathodic Protection ;t Rotary Type of Grout <br /> Disposal Other :_._. ' Other Information <br /> Geophysical Surface Seal Installed BY: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump Z H.P. Y T— ff <br /> PUMP REPLACEMENT:. . / / State Work Done <br /> j et <br /> PUMP ;REPAIR: - .State Work Done <br /> ' Rawl1 <br /> DESTRUCTION OF WELL: Well Diameter �' Approximate Depth <br /> Describe Materialrand Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin .Local Health District <br /> and the State of California -pertaining to or,'regulating well ''construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting,the .well in.use.... .The above <br /> information is true to the•best•of' my-k wledge elief. I WILL CALLOR A 'GROUT INSPECTION <br /> PRIOR TO GMUFNG AND A SINAL INSP 0 <br /> SIGNED K - t ITLE <br /> �� (5EWELOT PLAN ON RE RSE SIDE <br /> OR DEPARTMENT USE ONLY <br /> PHASE I / <br /> APPLICATION ACCEPTED BY DATE <br /> ADDITIONAL COMMENTS <br /> PRASE II GROUTkrNSPECTION PHASE III FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY _ DATE 17 <br /> 4/75 2M <br /> E $ 1425 Rev. 1--74 r' <br />